Health Care Matters | April 25, 2025
Health Policy Tracker: Trump’s First 100 Days
Impacts of HHS Restructuring
Recent reports reveal the impending impact of HHS regional office closures, with industry leaders warning of significant delays in essential functions like Medicare claims appeals and safety inspections as the remaining offices struggle to absorb new oversight responsibilities amid massive workforce reductions. For more, read the following:
UnitedHealth and Elevance Health Report Divergent Q1 Results
Elevance Health reported strong Q1 2025 results despite elevated Medicare Advantage costs, with earnings surpassing Wall Street expectations. The company affirmed its 2025 guidance, maintaining its prediction for adjusted net income and Medicare Advantage membership growth to 2.3 million members. In stark contrast, UnitedHealth Group, typically a reliable performer that hadn't missed earnings estimates since the 2008 financial crisis, shocked the industry with a significant earnings miss citing rising medical costs in its Medicare Advantage plans and "unanticipated changes" in its Optum health services subsidiary. Read more here and here.
Why It Matters
The divergent results have triggered significant market reactions with major implications for the broader healthcare insurance sector. These mixed performances highlight growing uncertainty in the Medicare Advantage market, which now covers more than half of eligible Medicare beneficiaries. The sector faces increasing scrutiny over allegations of excessive care denials and overpayments, with the Center for American Progress estimating overpayments cost the government up to $127 billion in 2024. The upcoming earnings reports from other major Medicare Advantage insurers will be closely watched to determine whether UnitedHealth's struggles represent an industry-wide problem or company-specific issues, particularly as open enrollment for 2025 approaches in October. However, the recent 5.06% payment boost announced by the Trump administration, representing an expected $25 billion increase to insurers, along with industry reports touting Medicare Advantage's superior care quality and cost efficiency compared to traditional Medicare, suggest continued government support for the program despite these challenges.
Medicare Advantage and Supplemental Long-Term Services and Supports: A Small Step in the Right Direction
A recent Health Affairs Forefront article examines Medicare Advantage (MA) plans' supplemental long-term services and supports (LTSS) offerings. While MA plans can now offer LTSS benefits like personal care, family caregiver support, and home modifications, the authors argue these offerings remain severely limited in scope and availability. 14 million adults currently require such services with over half of people 65+ likely to need LTSS in their lifetime. Yet MA plan offerings are sparse, with only 10% of plans offering personal care services, often limited to just 1-2 hours per week. Read here.
Why It Matters
This issue is particularly significant as the Trump administration appears poised to accelerate Medicare privatization with a strong pro-Medicare Advantage stance. The administration has already finalized a substantial 5.1% payment increase for MA plans in 2026 and signaled interest in making MA the default enrollment option for Medicare beneficiaries. While Trump's campaign pledged to prioritize home care benefits and support family caregivers through tax credits, these approaches favor market-based solutions through MA supplemental benefits rather than comprehensive public LTSS coverage. As America's population rapidly ages, this policy direction will likely widen the benefits gap between MA and traditional Medicare enrollees while maintaining the fragmented LTSS landscape. Without more robust solutions that extend beyond limited MA supplemental benefits, millions of older Americans will continue facing significant barriers to receiving the support they need to age with dignity in their homes and communities.
Look for the Helpers: This Doctor’s Primary Care Startup Focuses On Keeping Older Adults Out Of The ER
After growing frustrated as an ER doctor watching patients arrive with chronic conditions that should have been addressed through primary care, Dr. Brent Asplin founded Gather Health in 2022 to serve high-risk older adults on Medicare and Medicaid, combining traditional medical offices with home care, remote monitoring technology, and social events to combat isolation. This comprehensive approach has shown impressive results with a 53% reduction in hospitalizations after 12 months across their 2,500+ patients in the greater Boston area, demonstrating how reimagining primary care delivery can improve health outcomes while creating a sustainable business. Read here.
What We Are Reading
A Call for Reform: Fraud, Waste & Abuse in Medicare Requires Sweeping Action
A new report co-authored by Pearl Health and Falcon Health leaders argues that Medicare must implement sweeping reforms to combat fraud, waste, and abuse through advanced analytics for proactive detection, streamlined resolution processes, and alignment with value-based care goals to ensure program sustainability as the trust fund faces insolvency by 2033. Read here.
Affordable Commercial Health Insurance Is Available—If We Want It
A new Health Affairs Forefront article argues that employers and employees can achieve affordable commercial health insurance without additional taxpayer subsidies by implementing tiered networks based on total cost of care, placing accountability in the hands of providers and consumers rather than insurance companies. Read here.
Area-Level socioeconomic disadvantage and access to primary care: A rapid review
A rapid review of 31 studies found that higher area-level socioeconomic disadvantage, measured by the Area Deprivation Index or Social Vulnerability Index, was consistently associated with reduced primary care access, particularly for self-reported access, vaccine uptake, and use of telephone versus video telemedicine, with implications for telemedicine payment policy and community-level interventions. Read here.
Pop health podcast
Advancing Value-Based Care: Progress, Gaps, and Policy Signals
In the latest episode of the Pop Health Podcast, we explore the current state of value-based care with Emily Brower and Mara McDermott, including recent policy developments, emerging trends, federal alignment, and practical tips for tracking meaningful changes in the VBC landscape.